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Complaint Investigation

Avir At Rose Trail

August 15, 2025 · Tyler, TX · 930 S Baxter
Citations 2
CMS Rating 1/5
Beds 172
Provider ID 455429
Healthcare Facility
Avir At Rose Trail
Tyler, TX  ·  View full profile →
Inspection Summary

Avir at Rose Trail in TYLER, TX — inspection on August 15, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Immediate Jeopardy

The surveyor confirmed the facility had corrected the non-compliance prior to survey starting by: Record review of the Resident #1's monitoring log dated 8/10/25 indicated Resident #1 was on one-to-one monitoring beginning 8/10/25 at 7:00 p.m. and continued until 8/11/25 at 11:00 a.m when she was transferred to a memory care unit at another facility.

Record review of in-services dated 8/11/25 indicated all active staff were in-serviced regarding wandering and elopement, safety and supervision of residents, missing persons policy and procedure, and alarmed entrance and exit doors and the new door monitoring log policy.

Staff interviewed (LVN A, LVN B, LVN C, RN D, RN E, CNA F, CNA G, CNA H, and CNA J) on 8/13/25 between 11:00 a.m. and 4:07 p.m. were able to articulate the content of the new door log book policy, and what to do in the event of an elopement.

Staff interviewed said that they would notify the charge nurse and attempt to redirect the resident if they saw someone attempting to elope from the facility.

Investigator ensured all exits armed with Wanderguard system were in working order by approaching each exit with a Wanderguard device and hearing the alarm sound.

The noncompliance was identified as PNC IJ.

The noncompliance began on 8/10/2025 and ended on 8/11/2025.

The facility had corrected the noncompliance before the survey began.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Rose Trail Nursing and Rehabilitation Center

930 S Baxter Tyler, TX 75701

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 8/14/25 at 2:56 p.m. the Physician said he did not know about tracheostomies and did not want to give his medical opinion as he is not familiar with facility policy.

The Physician said the nurses should call emergency medical services in the event of an emergency and should be able to care for Resident #2 in the event of an emergency.

The Physician said the surveyor should talk to a respiratory therapist regarding the importance of having necessary supplies in the facility for tracheostomy treatment as he was not sure of the facility policy.

During an interview on 8/15/25 at 9:45 a.m. the RT said the facility should have in the emergency tracheostomy kit at bedside a tracheostomy tubes the same size and one size smaller than what the resident has inserted, an ambu bag, and a suction catheter.

The RT said most of the time in the event of decannulation a tracheostomy tubes the same size was not able to be re-inserted and a tracheostomy tube one size smaller was required.

The RT said in the event of a life-or-death emergency a tracheostomy tube one size smaller that the sterile packaging had been opened on could be used.

The RT said most tracheostomy patients were able to breath without the tracheostomy unless it was a brand-new tracheostomy.

Record review of the facility's Tracheostomy Care policy dated 2001 indicated, The purpose of this procedure is to guide tracheostomy care ant the cleaning of reusable tracheostomy cannulas.A replacement tracheostomy tube must be available at the bedside at all times.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TYLER, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Avir at Rose Trail or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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